Gangemi Michelangelo, Maiuri Francesco, Buonamassa Simona, Colella Giuseppe, de Divitiis Enrico
Department of Neurological Sciences, Section of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
Neurosurgery. 2004 Jul;55(1):129-34; discussion 134. doi: 10.1227/01.neu.0000126938.12817.dc.
To define the role and indications for an endoscopic third ventriculostomy (ETV) in patients with idiopathic normal pressure hydrocephalus (INPH). A series of 25 patients treated by endoscopic technique was analyzed, and the results were compared with those of 14 studies reporting patients treated by shunting.
Twenty-five patients with INPH were treated by ETV from January 1994 through December 2000. All were younger than 75 years of age, had a preoperative clinical history of 1 year or less, had prevalence of gait disturbance with scarce or mild dementia, had marked ventricular enlargement on magnetic resonance imaging (MRI), and had intracranial pressure values ranging from 8 to 12 mm Hg. All were studied by a phase-contrast MRI flow study 1 month after ETV. The 14 reviewed series of patients treated by shunting (all published after 1980) each include more than 25 patients, for a total of 777 patients.
The overall rate of neurological improvement after ETV in our series was 72% (including two patients reoperated on because of absence of flow in the MRI scan); this percentage is slightly higher than that found in the 14 series of shunted patients (66%). Gait disturbance showed a high rate of improvement when compared with other symptoms, both in our ETV study and in other shunting series. Postoperative complications occurred only in one patient (4%) with an intracerebral frontal hemorrhage and in 37.9% of patients from the series including shunted patients.
In patients with INPH showing short duration of symptoms, prevalence of gait disturbance, and slight mental impairment, ETV provides similar results to those of shunting. We suggest performing ETV in these patients and reserving shunting only for those who do not improve after ETV, despite the presence of cerebrospinal fluid flow through the ventriculostomy on MRI flow studies. The good results after ETV in our series indirectly confirm that the cerebrospinal fluid absorption is good or at least sufficient in selected patients with INPH.
明确内镜下第三脑室造瘘术（ETV）在特发性正常压力脑积水（INPH）患者中的作用及适应证。分析了25例接受内镜技术治疗的患者，并将结果与14项报道分流治疗患者的研究结果进行比较。
1994年1月至2000年12月，对25例INPH患者行ETV治疗。所有患者年龄均小于75岁，术前临床病史为1年或更短，步态障碍伴轻度或无痴呆，磁共振成像（MRI）显示脑室明显扩大，颅内压值为8至12mmHg。ETV术后1个月，所有患者均接受相位对比MRI血流研究。回顾的14项分流治疗患者系列研究（均发表于1980年以后）每项均包括超过25例患者，共计777例患者。
在我们的系列研究中，ETV术后神经功能改善的总体发生率为72%（包括2例因MRI扫描显示无血流而再次手术的患者）；该百分比略高于14项分流患者系列研究中的发生率（66%）。在我们的ETV研究和其他分流系列研究中，与其他症状相比，步态障碍的改善率较高。术后并发症仅发生在1例患者（4%），为脑额叶出血，而在包括分流患者的系列研究中，并发症发生率为37.9%。
对于症状持续时间短、步态障碍且轻度精神障碍的INPH患者，ETV的效果与分流相似。我们建议对这些患者行ETV，仅对那些尽管MRI血流研究显示脑脊液通过脑室造瘘口流动，但ETV后仍无改善的患者进行分流。我们系列研究中ETV后的良好结果间接证实，在部分INPH患者中脑脊液吸收良好或至少足够。
